- Discussion: (see vancomycin and addition of antibiotics to cement,  vanc in ca sulfate and local delivery of antibiotics to infected joints):
- dosing:
             - as much as 4 gm of vancomycin (as well as 4.6 gm of tobramycin) can be used per batch of cement;
- note that the cost for a 1 gm vial is about 40 US dollars;
- in the study by Masri, et al, authors conclude that at least 3.6 g of tobra and 1 g of vanc per package of bone-cement is recommended when
antibiotic-loaded cement spacers are used in 2-stage exchange arthroplasty for infected total hip and knee arthroplasties;
- there was a significant increase in elution of vancomycin when dose of tobra was increased from at most 2.4 g to at least 3.6 g;
- Long-term elution of antibiotics from bone-cement: an in vivo study using the prosthesis of antibiotic-loaded acrylic cement (PROSTALAC) system.
       - local pharmokinetics vs systemic:
              - has much slower and more consitent elution characteristics than tobramycin and gent;
- vancomycin shows very poor tissue penetration, which is a disadvantage of IV infusion;
- in contrast, w/ local application there will also be reduced penetration from the implanted site into the vascular system, which
keeps local tissue levels high and systemic levels low;
- references:
- Release of gentamicin and vancomycin from temporary human hip spacers in two-stage revision of infected arthroplasty.
- Elution of gentamicin and vancomycin from polymethylmethacrylate beads and hip spacers in vivo
- High concentration and bioactivity of vancomycin and aztreonam eluted from Simplex cement spacers in two-stage revision of infected hip implants: a study of 46 patients at an average follow-up of 107 days.
- vivo and in vitro studies of antibiotic release from and bacterial growth inhibition by antibiotic-impregnated polymethylmethacrylate hip spacers.
- safety:
              - vancomycin shows the least cytotoxic effect of all commonly used antibiotics and is not likely to cause systemic side effects after local application;
- in the report by Springer, et al total antiobiotic load of 10.5 g of vanc and 12.5 g of gent was clinically safe, w/ no evidence of acute
renal insufficiency or other systemic side effects;
- in the study by Evans, et al, the authors used 4 g of vanc and 4.6 g of tobra per 40 gm batch of cement in 54 periprosthetic joint infections;
- at 2-year follow up there were no no renal, vestibular, or hearing changes;
- Systemic safety of high-dose antibiotic-loaded cement spacers after resection of an infected total knee arthroplasty.
- Successful treatment of total hip and knee infection with articulating antibiotic components: a modified treatment method.
      - biofilm: bactericidal activity:
              - vancomycin is one of the antibiotics with intracellular bactericidal activity and therefore should cover small colony variants of staphylococci and MRSA;
- penetrates glycocalices very rapidly;
- once incorporated in biofilm Vancomycin shows a strain dependent bactericidal biofilm activity between 8 times and 128 times the MIC of planktonic bacteria;
- shows superior bactericidal activity against biofilm embedded staphylococci and MRSA compared with most other antibiotics;
- references:
- Impact of biofilm on the in vitro activity of vancomycin alone and in combination with tigecycline and rifampicin against Staphylococcus aureus.
- Comparison of biofilm-associated cell survival following in vitro exposure of meticillin-resistant Staphylococcus aureus biofilms to the antibiotics clindamycin, daptomycin, linezolid, tigecycline and vancomycin.

- references:
      - Use of vancomycin and tobramycin polymethylmethacrylate impregnated beads in the management of chronic osteomyelitis.
- Elution characteristics of vancomycin and tobramycin combined in acrylic bone-cement.
- Antibiotic impregnated bone cement in total hip arthroplasty. An in vivo comparison of the elution properties of tobramycin and vancomycin.
- Impregnation of vancomycin, gentamicin, and cefotaxime in a cement spacer for two-stage cementless reconstruction in infected total hip arthroplasty.
- Elution of vancomycin, daptomycin, and amikacin from acrylic bone cement.
- A sixty-five-year-old man with rash, fever, and generalized weakness.
- Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty
- In vitro inhibition of coagulase-negative staphylococci by vancomycin/aminoglycoside-loaded cement spacers.
- In vitro activities of daptomycin-, vancomycin-, and teicoplanin-loaded polymethylmethacrylate against methicillin-susceptible, methicillin-resistant, and vancomycin-intermediate strains of Staphylococcus aureus.